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General NPI Number Information
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NPI Number | 1568653665
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Entity Type | Organization
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Legal Business Name | DIERCKS FAMILY HEALTH CTR., LLC
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 08/05/2007
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Provider Practice Location Address
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Address Line | 1111 LANGLADE RD
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City | ANTIGO
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State | WI
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Zip | 54409-2738
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Country | US
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Telephone | 715-623-3761
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Fax | 715-623-3764
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Provider Business Mailing Address
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Address Line | 1111 LANGLADE RD
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City | ANTIGO
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State | WI
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Zip | 54409-2738
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Country | US
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Telephone | 715-623-3761
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Fax | 715-623-3764
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | AMANDA R DIERCKS
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Credential | D.C.
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Telephone | 715-623-7812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 4179-012
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License Number State | WI
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